AGENCY: Department of Health. Bureau of Maternal and Infant Health Services

SERIES: 82220
TITLE: Maternal and infant health authorization forms
DATES: 1987-1993.
ARRANGEMENT: Alphanumerical by program

DESCRIPTION: This is an authorization by the bureau for the clinics to bill the program. It includes the provider's name and number, the recipient's name and number, the services authorized, the amount authorized, the date of service, the services rendered, and the amount charged.

RETENTION

DISPOSITION

RETENTION AND DISPOSITION AUTHORIZATION

These records are in Archives' permanent custody.

APPROVED: 12/1987

FORMAT MANAGEMENT

Paper: Retain in Office for 6 months and then destroy.

APPRAISAL

Administrative

The record copy of this form is kept in the patient chart. This copy has only administrative value.

PRIMARY DESIGNATION

Private

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